Provider Demographics
NPI:1083484752
Name:HYDE, SHANNON JAUREGUI (MFT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JAUREGUI
Last Name:HYDE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:874 8TH ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-2114
Mailing Address - Country:US
Mailing Address - Phone:619-890-9627
Mailing Address - Fax:
Practice Address - Street 1:2114 NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2209
Practice Address - Country:US
Practice Address - Phone:619-890-9627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87377106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist